Introducing Resident Directed Care and Nursing Home Culture Change: A Case Study

1. Introducing Resident Directed Care and Nursing Home Culture Change: A Case Study Christine Mueller, PhD, RN, FAANUniversity of MinnesotaSchool of NursingMathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAANEthel Mitty, EdD, RNHartford Institute for Geriatric Nursing New York University College of Nursing Module 5 of Nursing Homes as Clinical Placement Sites for Nursing Students Series

2. Acknowledgments This is a joint project of With support from Grant to the University of Minnesota School of Nursing

3. This project is endorsed by: Project Steering Committee View List of Members

4. About Module 5- Introducing Resident-Directed Care and Nursing Home Culture Change: A Case Study In a culture change nursing home: assist faculty to structure student clinical experiences In a traditional nursing home: integrate principals of culture change and resident-directed care into the clinical experience In both types of nursing homes: collaborate with nursing home staff to create learning experiences that promote student understanding of resident-directed care Objectives/Purpose: At the end of this module you will be able to:

5. Scenario: School of Nursing Erica Meyers, MSN, BC, RN, is a gerontological clinical nurse specialist on the faculty at Astor University School of Nursing. A recent revision in the curriculum includes a clinical experience for undergraduate students in a nursing home as part of a geriatric nursing course.

6. Focus of Students’ Clinical Experience Provide students with opportunities to apply knowledge about geriatric care with a particular focus on the frail older adult Acquire an understanding of culture change and resident-directed care

7. Goals for Nursing Home Selection • Erica’s goal is to select 2 nursing homes engaged in transforming from an institutional (traditional) model to a resident-directed care model • In a resident-directed care home: • Care focuses on resident needs, wants, habits and preferences • Students have positive learning experiences and are encouraged to consider a career in long-term care

8. Goals for Nursing Home Selection Erica identified all nursing homes in a 25 mile radius of the university by going to the CMS web site Nursing Home Compare, http://www.medicare.gov/NHCompare/ Nursing Home Compare provides information about nursing home quality, including the CMS 5 Star Rating Click here to view the Nursing Home Compare Website

9. Erica found six nursing homes whose CMS quality ratings varied from 2 to 5 stars. On CMS quality of care and life measures, two homes (Spring Lake and River Shores) ranked higher than other homes in the state and the U.S. • Note: Nursing Home Compare did not provide information about whether or not these nursing homes were engaged in culture change. Spring Lake River Shores

10. Identifying Culture Change Nursing Homes To verify if these two nursing homes had a resident-directed care philosophy, Erica: 1 Identified her state coalition website through the Pioneer Network State Nursing Home Culture Change Coalition http://www.pioneernetwork.net/Coalitions/Websites 2 Spoke to her state coalition representative 3 Recorded her findings

11. Erica’s Findings Spring Lake had been engaged in culture change for 6 years and was well known for their quality of care River Shores had a good reputation for quality of care with traditional care practices

12. Evaluating the Culture Change Nursing Home: Spring Lake Web Site Spring Lake web site shows that it was designed with neighborhoods* that have: Private room and bath for every resident Permanentstaff focusing on resident preferences and abilities and Residents pursuing their individual interests *Neighborhoods consist of : Small units of 8-20 residents Consistent staff assignment Separate dining and living areas Local (i.e., community) decision making To view a profile of a nursing home, click on the following link: http://www.innovations.ahrq.gov/content.aspx?id=1906

13. Evaluating the Traditional Nursing Home: River Shores Web Site River Shores web site shows that it provides: Care for persons needing medical supervision by licensed nurses Help and support for physical and emotional well-being A comfortable and supportive environment Availability of 24 hour medical personnel Private and semi-private rooms

14. Arranging to Visit the Culture Change Nursing Home: Spring Lake Below is the phone conversation between Erica and Jan Avery, BSN, RN, BC, Spring Lake Director of Nursing Erica: Hello, Jan. My name is Erica Meyers and I am on the nursing faculty at Astor University. I am interested in having our nursing students learn about geriatric nursing and resident-directed care at Spring Lake. I understand that Spring Lake has been on the nursing home culture change journey for six years. Jan: That is correct, Erica. I am pleased that you know about us and am interested in exploring having nursing students at Spring Lake Erica: Can we arrange a time for me to come to Spring Lake? Jan: Yes, and I’d like you to meet with some of the nursing staff and residents. Erica: I could come next week Wednesday at 2 p.m. Jan: That’s a good time. Every afternoon some residents are planning the meal menus for the next day and baking the dessert for the evening meal. Erica: Great! I look forward to spending time at your residents’ home.

15. Arranging to Visit the Traditional Nursing Home: River Shores Below is the phone conversation between Erica and Sue Jones, BSN, RN, BC, River Shores Director of Nursing Erica: Hello, Jan. My name is Erica Meyers and I am on the nursing faculty at Astor University. I am interested in discussing clinical placements for our nursing students at River Shore. Sue: I would be very interested in exploring having nursing students at River Shore. We pride ourselves on our excellent nursing care Erica: We are committed to exposing students to homes with excellent care. We also want students to learn about resident-directed care. Does this philosophy happen at River Shore? Sue: Our leadership team is discussing culture change and plans to introduce it to staff soon Erica: Could we arrange a time for me to come to River Shore? Sue: Yes, and I would like you to meet some of our registered nurses and learn how they assure quality nursing care for residents Erica: I could come next week Thursday at 10am Sue: That’s a good time. I can give you a short tour and you can sit in on nurses’ care rounds for residents at high risk for falls Erica: Great! I look forward to meeting you and your staff and learning more about River Shore

16. Helpful Resources in Preparing to Visit the Nursing Homes These resources helped Erica prepare to evaluate the quality of each home and their involvement in/commitment to resident-directed care Observable Indicators of Nursing Home quality Instrument (Rantz et al, 2006)* http://www.nursinghomehelp.org/OIQaL.pdf Artifacts of Culture Change http://www.pioneernetwork.net/Providers/Artifacts/ http://culturechangenow.com/pdf/artifacts.pdf Resources from the Pioneer Network re: Consistent Staff Assignments , http://www.pioneernetwork.net/Providers/Continuum/CareAssign/ Dining Practices, http://www.pioneernetwork.net/Providers/Continuum/Dining/ Bathing Practices, http://www.pioneernetwork.net/Providers/Continuum/Bathing/ Medication Administration, http://www.pioneernetwork.net/Providers/Continuum/Medication/ Click here to view content on resident directed care and culture change: Module 3: Resident Directed Care and Culture Change

17. Visit to the Culture Change Nursing Home: Spring Lake A resident greeted Erica at the neighborhood door. Erica walked through the neighborhoods observing and talking with staff and residents. Erica used the resources to evaluate the environment, quality of professional nursing care, and resident-directed care practices.

18. Visit: Spring Lake When visiting Spring Lake, these are some of the things Erica saw:

19. Evidence of Culture Change: Spring Lake Neighborhoods had no visible nurses station Medications kept in the residents’ room; no visible medication carts Residents could choose what they wanted to eat and could eat meals on their own time schedule Food was available 24 hrs/day Residents’ care plans were called “I-Care Plans,” e.g. care plans in the resident’s voice and developed together by resident and staff For examples of “I” care plans, see the following links: http://jeny.ipro.org/showthread.php?t=2006 “I” Care plan example- Riverview Care Center “I” Care plan example- Clark-Lindsey Village

20. Student Learning: Spring Lake Erica told Jan about the objectives and content of the geriatric nursing course and resident-directed care Jan brought in Lisa Thomas, RN, BSN, BC, coordinator for two of the neighborhoods available to students. Together, they identified potential student learning experiences about resident-directed care. Students work with nursing assistants to learn how to bathe residents with dementia Role of the professional nurse in culture change Click to view Culture Change background paper Students shadow the nurse coordinator to learn about the role of the professional nurse and nursing home culture change Students attend meetings as staff plan the day according to the residents’ preferences Students participate in an interdisciplinary care meeting with a resident and their family Students develop I-Care Plans for their residents Click to view sample I-Care Plan Click to view article regarding bathing older adults with dementia

21. Staff Learning: Spring Lake Erica discussed the use of evidence-based geriatric nursing assessment and interventions Jan& Lisa indicated a desire to educate themselves and staff about evidence-based care Erica showed them the website www.ConsultGeriRN.org. She specifically reviewed the: The Try This® Assessment Series The How to Try This assessment videos The AJN Series on How to Try This Evidence-based Protocols Erica shared two examples of student assignments that students will have as part of their experience at Spring Lake

22. Student Assignment: Resident Assessment - Spring Lake Example 1: A student conducts a cognitive assessment with a resident using 2 standardized instruments. In the clinical conference, the student will describe: • The purpose of the assessment instrument • The results of the assessment • The interpretation of the results • How their findings compare with recent MDS and medical diagnoses of the resident

23. Student Assignment: Observing Resident Behavior - Spring Lake Example 2: A student observes behavioral symptoms of residents with cognitive impairments. In the clinical conference, the student will describe: • Observed behavioral symptoms • Potential causes of behavioral symptoms • Effectiveness of strategies that nursing staff used to reduce/minimize symptoms • Comparison of staff practices used to bathe residents with the nursing literature

24. Creating a Learning Partnership: Spring Lake Jan & Lisa were enthusiastic about creating a plan for staff professional development re evidence-based assessment and care. They proposed: Students conduct a “journal club” for staff Staff review assessments and protocols on www.ConsultGeriRN.org Partnering to develop evidence-based policies and procedures for Spring Lake

25. Preparing for Student Experiences: Spring Lake Erica, Jan & Lisa identified how to prepare for student experiences at Spring Lake Resources to assure that students understood resident-directed care and culture change Time for Erica to meet with: Staff to explain student rotations Residents to determine their willingness to have students assist them with their care

26. Visit to the Traditional Nursing Home: River Shores Erica was greeted by a receptionist at a desk in the foyer area. The receptionist paged Sue on the overhead pager. While Erica was waiting for Sue, she talked to several residents who were sitting in the foyer in wheelchairs. Several minutes later, Sue greeted Erica and they toured the home. Erica observed and talked to nursing staff and some residents during the tour. Erica used her resources to evaluate the environment, quality of professional nursing care, and person-directed care practices.

27. Visit: River Shores When Erica visited River Shores, these are some of the things she saw:

28. Evidence of Traditional Care: River Shores • At River Shores, consistent with a more traditional nursing home, Erica observed: • The home arranged in 2 “wings” with nurses station in center and four hallways off the nurses station • Residents dressed and sitting in wheel chairs around nurses station • Two medication carts with nurses administeringmeds in the hallway and in resident’s rooms • A main dining room and posted mealtimes • Staff smiling and laughing with residents • Nursing assistants offering water to residents • Staff conducting exercises in lounges on each wing

29. Student Learning: River Shores Erica told Sue about the objectives and content of the geriatric nursing course and resident-directed care Sue brought in Alice Trent, RN, BSN, BC, Asst. Director of Nursing. They had implemented evidence-based care but were very early in introducing resident-directed care. Together, they identified potential student learning experiences about resident-directed care. • Students review how current nursing care practices for bathing, dining, medication administration, staff assignments will change when River Shore starts to implement resident-directed care • Students develop a model “I” care plan in a resident’s voice

30. Staff Learning: River Shores Erica discussed early steps to introduce resident-directed care. Sue & Alice were enthusiastic to educate themselves and staff about resident-directed care. Together they agreed to implement the following activities: • A Learning Circle with staff and students to discuss: • What does “home” mean to you? • When you come to a nursing home to live, what will make if a “home” for you? Click to view guidelines for a Listening and Learning Circle • Students to develop and share their resident-directed “I” care plans with staff • Students to start and run a journal club to discuss the article “Bathing the Older Adult with Dementia,” • Nursing staff to receive a copy of the article in advance • Lunch served Click to view article regarding bathing older adults with dementia

31. Preparing for Student Experiences: River Shores Erica, Sue & Alice identified how to prepare for student experiences at River Shore. Resources will be developed to assure that students understand resident-directed care and culture change. Scheduled a time for Erica to meet with: • Staff to explain student rotations • Residents to determine their willingness to have students assist them with their care Learn more about resources for resident-directed care

32. Recap: Key Points about Introducing Resident-directed Care and Nursing Home Culture Change: A Case Study • Staff in a culture change nursing home can: assist faculty to select and structure student clinical experiences in resident-directed care • Staff in a traditional nursing home can: learn theprincipals of culture change and, working with the faculty and students, integrate resident-directed care into the students’ clinical experience • In both types of nursing homes: faculty collaborate with nursing home staff to create learning experiences that promote student understanding of resident-directed care in established culture change nursing homes and in transitioning nursing homes. We present the following key points to consider:

33. Please Proceed to the following modules of the SeriesNursing Homes as Clinical Placement Sites for Nursing Students Overview of the Project Module 1: An overview of nursing homes generally Module 2: An overview of nursing in nursing homes Module 3: Content on resident directed care and culture change Module 4: Selecting and structuring clinical placements in nursing homes Module 5: A case study to help faculty introduce resident directed care and culture change Module 6: Strategies to help nursing homes position themselves as clinical placement